Provider Demographics
NPI:1861631640
Name:COPPER HEIGHTS
Entity Type:Organization
Organization Name:COPPER HEIGHTS
Other - Org Name:LEGACY SENIOR MANAGEMENT, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:A/R COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-8203
Mailing Address - Street 1:152 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8718
Mailing Address - Country:US
Mailing Address - Phone:480-985-0680
Mailing Address - Fax:480-396-6231
Practice Address - Street 1:152 N 56TH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8718
Practice Address - Country:US
Practice Address - Phone:480-985-0680
Practice Address - Fax:480-396-6231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-6182310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ212195Medicaid